Transcription of BACKGROUND CHECK REQUEST Adult Care Home Program …
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BACKGROUND CHECK REQUEST Adult Care Home Program …
BACKGROUND CHECK REQUEST . Adult Care Home Program Aging, Disability & Veterans Services Division BACKGROUND CHECK REQUEST New (must be seen in person) Renewal ($ fee). APPLICANT INFORMATION: Please attach a color copy of your current government- issued photo ID. 1. Last Name 6. Type of ID: Driver's License/State ID. Passport Other: 2. First Name 7. Government ID State or Country of Issue 3. Middle Name 8. Government ID Number 4. Other Names Used (last, first, middle) 9. Social Security/ITIN Number (optional, for statewide portability). 5. Date of Birth 10. Gender Male Female X Other/Nonbinary CONTACT INFORMATION.
complete the “Disclosures and Authorization” portion of this Background Check Request. The link will work from any computer, tablet or smartphone that has internet access. When you sign on to this link, be prepared to provide information about the following questions. If you
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